Unusual presentation of opioid withdrawal as seizure in Indian population

AIM: To study unusual presentation of opioid withdrawal in opioid userss METHODOLOGY: Patients coming to avail services from Emergency and OPD with opioid withdrawal were taken using convenience sampling. Out of 30 opioid withdrawal patients screened, 3 presented with seizure as a primary symptom. CASE DESCRIPTION: Three male patients aged 20,29,24 years with Opioid withdrawal symptoms presented with generalized tonic clonic seziures within 2-5 days of their last opioid use. All three were consuming opioid in form of Smack (street form of heroin) in dependence pattern in large amounts with an average of 1-1.5 gram per day. Any other drug use and other possible causes for such presentation were ruled out with help of detailed examination and exhaustive investigations including urine drug screening and neuroimaging leaving only possibility of opioid withdrawal. DISCUSSION: Standard textbooks are silent on such complication due to opioid withdrawal despite evidence of opioid withdrawal seizures in infants of opioid dependent mothers. The already published data reveals that similar complicated opioid withdrawal is seen in subjects abusing impure form of opioids with impurities being the offending agent. While this cannot be completely refuted, various other probable mechanisms for association have been described involving opioid receptors and activity of neurons in the brain circuitry. CONCLUSION: Unusual rare presentation of seizure could be a primary manifestation of opioid withdrawals and needs stringent evaluation and management.